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SSL SK SHIP# 218916942 ` IIII�III�IIIIIIIIIIII I1III) III <br /> 0053293145 K5 <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number CATOOOEI-7968 7 <br /> 1 of 3.Empmpo4Y Response Phgoe� 4.Manifest Tracking Number <br /> WASTE MANIFEST 1 tlV1O 4F tl 1 I b 005329314 SKS <br /> 5.General Name and MellingAddress Generatces SiteAddress dtlifered than mailing address) <br /> SAFETY—KLEENSYSTEMS, INC. SAFETY—KEEN SYSTEMS, INC. <br /> PO BOX 555 5050 SALIDA BLVD <br /> SALIDA CA 95368 <br /> Generators Phone: 209-545-1011 SALIDA CA 95368 <br /> 6.TWann&R` SYSTEMS, INC. U.S.EPA ID Number TXROOOO812O5 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> B.Designated Facility Name and Site Address SAFETY—KLEEN OF CALIFORNIA, INC. U.S.EPA ID Number <br /> 6880 SMITH AVE. <br /> NEWARK , CA 94560 <br /> 510-795-4400 CAD98O8,4741A <br /> Facility's Phone: <br /> gra 9b.U.S.DOT Descziption(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unci <br /> 13.Waste Codes <br /> HM and Perking Group(8 any)) No. Type Quantity Wt.Nd. <br /> 1 NON—RCRA HAZARDOUS WASTE LIQUID TT P 221 <br /> o (USED OIL) <br /> oc� (P O <br /> z Z. <br /> W <br /> (9 <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information TSD:EVG SAL �:SG; <br /> 24 HR EMERGENCY #1-800-468-1760 (SK i TFI) <br /> RUTH AS "AGENT—FOR" BY GEN TO RETAIN LICENSED SUB CARRIERS AS NECESSARY <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and Iabeledlplacarded,and am in all respects in proper condition for transport according to applicable international and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment ofsent. <br /> I certify Nat the waste minimization statement identified in 40 CFR 26227(a)(it I am a large quantity generator)or(b) 1 all/small quantity generator)is true. <br /> Generato OBerols Printted/Typed eName Signal Month Day Year <br /> �—/e 1c)31 JJ I jf(r> <br /> J 16.International Shipments <br /> i ❑Import to U.S. LJ EW from U.S. Port ofentry/exk: <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> W 17.TransporterAcknoWedgment of Receipt of Materials <br /> Trani 1 Printed/Typed Name Signature Month Day Year <br /> O � <br /> aPTI AD /6 <br /> y <br /> Transponer2 Pdnted?yped Name Signature Monty Day Year <br /> K <br /> H <br /> 18.Discrepancy <br /> 18a,Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> rax. Facility's Phone: <br /> w 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> H19.Hazardous Waste Report Management Method Codes(i.e.,cades for hazardous waste treatment,disposal,and recycling systems) <br /> 0 1 O r!> [ 2. 3. 4. <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest Pei as noted in Item 1B <br /> Pdm yped Name Sign Month Day Year <br /> C 6 S <br /> EPA Form 8700-22(Rev.3-05 Previous editions are obsolete. DE I NAT ACILITYTO DESTINAT STATE(IF REQUIRED) <br /> 1) 11249/15601 <br />